Shared Vision

Shared Vision and Progress to Date : 

Shared Vision and Progress to Date Laura Mabie, MD Brian Prestwich, MD Marian Earls, MD April 2010

The “Medical Home” : 

The “Medical Home” Personal Physician Care Team Primary Care Whole Person Orientation Coordination/Integration of Care Quality/Safety Enhanced Access Financing

Pondering Competency : 

Pondering Competency “To be competent you must feel bad.” Hubert Dreyfus

Professional Competence : 

Professional Competence The habitual and judicious use of communication, knowledge, technical skills, evidence-based decision-making, emotions, values and reflection to improve the health of the individual patient and the community. Richard M. Epstein, MD and Edward M. Hundert, MD

Personal Knowledge : 

Personal Knowledge “Into every act of knowing there enters a passionate contribution of the person knowing what is known, and this is no imperfection but a vital component in his knowledge…”

“We know more than we can tell.” : 

“We know more than we can tell.” Training to evaluate the adequacy of theories and evidence which are the foundation of medical practice. Acts of judgment that cannot be reduced to following the rules of a specifiable protocol, or “tacit knowledge”. Objective knowledge and “tacit knowledge” are learned through apprenticeship to the practice of a truth-seeking community, rather than by reading a manual of technique. These “personal acts of discovery” are then offered for assessment and sifting within a competent community, whose judgments are made with the universal intent of gaining reliable knowledge of best practices The character of this encounter with the “competent community” is the controlling factor which prevents the individual’s personal knowledge from fragmenting into a loose collection of individual opinions.

Los Angeles County: Where Have We Been? : 

Los Angeles County: Where Have We Been? The vast majority of children are not effectively screened, and many disabilities go unrecognized: Nationally, 15-20% of pediatricians report using a structured developmental screening tool. 1/3 of parents in LA CO say they were asked about any concerns they may have regarding development at their last well child visit. Many children enter kindergarten unprepared and unable to function in the school environment.

Los Angeles County: Where Are We Now? : 

Los Angeles County: Where Are We Now? Emerging initiatives point to dramatic changes in the near future: EDSI I and II Practices Transformed EDSI Population Collaborative EDSI Residency Project EDSI AAP Collaborative Early Head Start and Head Start L.A. Universal Preschool “The goal of universal early identification and intervention is within reach.”

Change is Possible in Los Angeles: Improvement in Developmental Screening within 2007 Collaborative : 

Change is Possible in Los Angeles: Improvement in Developmental Screening within 2007 Collaborative For each month of the Collaborative, shows the average rate, highest rate, and lowest rate among medical practices

Results Achieved in First and Second EDSI Collaboratives : 

Results Achieved in First and Second EDSI Collaboratives Developmental screening rates at ages 9, 18 and 24 months increased: From 19% at baseline to 80% after 12 months (in first Collaborative, 2007-08) Narrowed the gap between practices (the lowest rate was 0% at baseline compared to the lowest rate of 60% after 12 months) Increased to 85% after 10 months (in second Collaborative, 2008-09)

Examples of Progress: Northeast Valley Health Corporation : 

Examples of Progress: Northeast Valley Health Corporation

Medical Homes Transformed Through EDSI : 

Medical Homes Transformed Through EDSI

The Saban Free Clinic PSPS : 

The Saban Free Clinic PSPS

Huntington Medical FoundationLa Canada Office : 

Huntington Medical FoundationLa Canada Office Life before EDSI Practice structure didn’t promote: Routine pattern of structured developmental screening Screening for maternal depression Tools to easily track and document screenings and results Fun with EMR

Getting Started : 

Getting Started Joined EDSI in October 2008 Met with our “team”, including: Dr. Neville Anderson Elizabeth Godinez – MA Debbie Hopps - IT Determined technology needs The first step is to determine what needs to happen to manage the project effectively… technology is key!

Changing our Technology : 

Changing our Technology Enhanced EMR program to help with documentation/tracking Added ASQ to test options Included detailed line items

Managing the Details : 

Managing the Details Scoring sheets are scanned into the chart ASQ and Maternal Depression screens

The Payoff : 

The Payoff Parent reaction Improved practice quality Screening results

Encouraging Further Collaboration : 

Encouraging Further Collaboration Our Practice 2 other offices in our practice began screening in October 2009 Developed relationships with local regional center

Encouraging Further Collaboration : 

Encouraging Further Collaboration Previous collaboratives focused on LA County AAP-EDSI collaboration to share knowledge across Chapters Current participants include practices from: AAP, California Chapter 2 and Chapter 4 Including: Ventura, LA, Orange, San Bernardino, and Riverside Counties

National Trends for Screening and Surveillance : 

National Trends for Screening and Surveillance ABCD (Assuring Better Child Health & Development) Commonwealth Fund Initiatives since 2000: ABCD I (2000–2003) ABCD II (2003–2006) Setting the Stage for Success (2006–2007) ABCD Screening Academy (July 2007)—involving 23 states AAP: 2001 & 2006 Policy Statements, Task Force on Mental Health, Bright Futures, 2007 Autism Screening Guidelines Rethinking Well-Child Care (AAP and Commonwealth) Tiered Well-Child Care (Commonwealth) SAMHSA—screening for social-emotional development Early Childhood Comprehensive Systems Grants (MCHB) Medical Home (AAP)

Imagine a Set of Systems That : 

Imagine a Set of Systems That Engages parents as partners in the primary care medical home, and respects them as experts on their children Helps parents, doctors, and nurses to promote the healthy development of children Enhances communication among parents, primary care providers, and community resources Leads to better policies to support children’s development Leads to better outcomes for children

EDSI Learning Collaborative Charter : 

EDSI Learning Collaborative Charter An Initiative to Promote Early Childhood Development

Collaborative Mission : 

Collaborative Mission The mission of the EDSI Learning Collaborative is to implement reliable and effective systems for effective preventive and developmental care for children less than 5 years of age. Teams from primary care practices will work to improve use of evidence-based strategies by supporting families’ efforts to promote positive developmental outcomes for their children.

Recommended Changes : 

Recommended Changes Teams will work in the following three areas: Implementing reliable and effective systems for preventive services and parent education Engaging parents in promotion of healthy development Using community resources effectively

Goals : 

Goals Each team is expected to adopt the collaborative goals to help focus their improvement efforts to achieve improved preventive and developmental outcomes for families and children. Goals for participating teams focus on measurable outcomes that are consistent with the collaborative mission, including:

Slide 29: 

>90% of parents report age-appropriate anticipatory guidance & parent education (AGPE) >90% of parents receive information to address concerns >90% of parents asked about substance abuse and family violence >75% of parents report reading to child daily >90% of parents report parent-centered care >95% of encounters include screening for parental depression, other psychosocial issues, and structured developmental screening >12 office systems in place Reliable and effective systems for preventive services/ parent education Engage parents in promotion of healthy development Ultimate Outcomes Prevent developmental & behavior problems Promote healthy development Intervene with problems early Use community resources effectively Goals Drivers Changes Aim: Promote healthy development for young children and achieve earlier identification and intervention for children with developmental or behavioral problems Use structured tools to elicit parent concerns and identify risks Prioritize health promotion activities based on parent concerns and risk factors Accessible patient education materials Implement early literacy promotion program Monitor use of structured tools Identify commonly used community resources Establish relationships with key resources Standardize referral Develop a referral tracking system Practice-wide guidelines for anticipatory guidance and parent education (AGPE) and preventive services Embed guidelines into clinical tools for planned care (e.g. Preventive Services Prompting System) Staff identifies and prompts clinicians about needed preventive services at well & non-well visits Use chart prompts/reminders Stratify patients Use a registry to manage high risk patients Monitor use of guidelines

Slide 30: 

Michael Polanyi, Personal Knowledge, Routledge and Kegan Paul, 1958. John Polkinghorne, Quantum Physics and Theology, An Unexpected Kinship. Yale University Press, 2007.